The medical history of an applicant is the basis for his acceptance or declination. This information is obtained through the answers to warranties in the application, the statements of the agent, the attending physician, reporting agencies or on physical examination. As far as possible the aim is to select risks that are in normal physical condition.
Certain diseases are apt to be recurrent in nature, some of which may result in a permanent organic disease, while in others the condition, causing a disability, is merely a symptom or manifestation of a seriously diseased condition. Age, height, weight, residence and occupation must be weighed with the past history.
To illustrate – Diseases of a recurrent nature are investigated as to the true number, dates and duration of such attacks, e. g., tonsillitis, rheumatism, appendicitis, gall stones or kidney stones, neurasthenia and malaria. Of the first two named, two or more attacks, coming at short intervals, indicate susceptibility and some ongoing companies may find it necessary to eliminate such diseases from the policy.
Appendicitis, gall stones and kidney stones predispose so strongly to subsequent attacks that a history of such precludes the acceptance or, if taken, calls for a waiver,unless the condition was very remote and the diagnosis doubtful.
Malaria brings up the relevant question of residence. If it is in a malarial district, recurrence is almost the rule. If the district is non-malarial, greater latitude is given, especially, if it was the first attack. Neurasthenia is a broad term, covering a multitude of various nervous manifestations. Such a history calls for declination, unless the disability has been very short. Nervous disability or breakdowns from overwork are the most frequent types. Recurrence is frequent and, fundamentally, these cases have an unstable nervous system and react poorly to their environment.
Some diseases may result in permanent organic disease. Syphilis, years after the primary infection, may show itself as locomotor ataxia, paresis, et cetera, an ulcer of the stomach become the seat of a cancer or urethral stricture result in prostatic hypertrophy and infections of the genito-urinary tract. Serious disease may manifest itself merely as a symptom and produce but little disability. For example, frequent headaches might mean nephritis; carbuncles, diabetes; asthma, heart disease; indigestion, appendicitis and gastric or duodenal ulcer.
Extremics of height and weight will show a low resistance and probably, if taken, their personal and family history is investigated. Claim records are carefully considered. The individual who puts in frequent claims for minor disabilities is an unprofitable risk. Thus, it is apparent that the selection of a ongoing health risk is not simple. Health claims in general follow a more or less uniform procedure.
Most of the ongoing companies require, when a Kaiser Calculator notice is received during the period of disability, a medical examination by one of its appointed medical examiners who makes his report regularly, not only giving the diagnosis and prognosis of the illness, but an estimate of the period of disability with such other remarks as are beneficial to the consideration of the claim and underwriting. With this in hand, the adjuster is prepared to furnish a final claim blank which gives the claimant’s statement as to period of disability and includes a certificate by the attending physician.
On receiving this, the adjuster has a file, containing notice, examiner’s report and completed claim, which enables him to measure the merits of the full case. In addition to the medical examiner’s report and the completed claim, an investigation may be made, but there can be no fixed time for this investigation, in that each case by its facts must be handled and governed accordingly.
For example, if a claim is not received at the final end of the estimated period given by the examiner, an investigation should be made, unless reliable information is at hand, explaining the delay. At times an investigation will be required before the final end of the estimated period of disability. At other times, after the claim is received, the facts shown by the different reports will not sufficiently correspond to satisfy the adjuster and an investigation is required.
In speaking of investigations it must be understood that they are almost without exception made by a layman and the object sought is to determine the facts of disability, which, in connection with a claim under the ongoing health policy, consists of absence from business, a period of confinement to the homely house and a period of non-confinement to the house.
Occasionally, the investigator is required to interview the attending physician in order to satisfy himself that the illness is of such a nature as to cause the Insured to remain away from his occupation or because the dates of disability given by the claimant do not agree with those of his physician. It is also occasionally necessary for an investigator to visit an insured for the purpose of explaining the coverage of the Health policy.